Child Care Request Form
Contact Information
First Name
Last Name
Street Address
City/Town
Other
Any additional contact information
Postal Code
ie - A9A 9A9
Major Intersection
Phone Number
Email Address
Fax Number
Child Care Requirements
How many children do you require care for?
Please select...
1
2
3
4
Date of Birth Child 1
MM/DD/YYYY
Date of Birth Child 2
MM/DD/YYYY
Date of Birth Child 3
MM/DD/YYYY
Date of Birth Child 4
MM/DD/YYYY
Date Care Required On
MM/DD/YYYY
What type of care are you looking for?
Licensed Child Care Centre
Licensed Home Child Care Agency
Select all that apply
Type of care needed
After School * (enter school name below)
Before School * (enter school name below)
Christmas Break
Co-op Nursery School
Evenings
Full Day
Full Time (5 days a week)
March Break
Montessori
Nursery School
PA Days
Part Day
Part Time (less than 5 days a week)
Shift Care
Short Term
Special Needs
Summer Camp
Weekends
Select all that apply
Name of school
If you selected 'Before School' and/or 'After School' above, please enter the name of the school.
Do you prefer that your child care be located near the address given above?
Yes
No
If no, is there another location that the care should be near? Please be specific (including an address or postal code if possible)
Do you require wheel chair accessibility?
Yes
No
Do you have any additional requirements (ie - language, accessibility, etc...)
Do you require programs that offer child care subsidy?
Yes
No
The fee subsidy is based on your family's total income and child care costs
Do you require information about child care subsidy?
Yes
No
Do you require programs that are participating in the Canada-Wide Early Learning and Child Care system?
Yes
No
Only families with eligible children enrolled in participating child care programs will receive lower fees. If your licensed child centre or licensed home child care agency does not participate, your provider is not required to lower your child care fees.
Additional Information
Have you used our service before?
Yes
No
If no, how did you hear about us?
Word of Mouth
Region of Halton
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Online
Other (please specify)
If other, please specify
We would like to know if our service has been of assistance to you. May we email you a short survey for feedback?
Yes, please contact me
No, don't contact me
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Contact Information